FORM FRM5121/1.1
Effective: 21/01/15
Therapeutic Apheresis Services
Request for Therapeutic Apheresis
Patient Demographics
Last Name
First Name(s)
NHS Number
D.O.B
Hospital Number
Patient Contact Number
Hospital
Ward /Outpatient
Consultant Name
Consultant Contact Number
Ward Contact Number
What type of procedure is required?
What is the diagnosis of the patient’s illness?
What is the indication for apheresis?
What is the target of apheresis?
How will the effectiveness of apheresis be measured?
Procedure Information
Number of apheresis procedures requested:
Over what time period:
Preferred date of first procedure:
Is the patient suitable for treatment on the apheresis unit?
Yes
No
Do you authorise NHSBT to manage patient fluids?
Yes
No
Human Albumin Solution (5% - 4.5%) and saline are standard replacement
fluid except for TTP when Octaplas is used. Does this patient require
different fluids?
Yes
No
If no, where will the procedures take place?
Height
Weight
Replacement Fluids
If yes, please
specify:
(Template Version 01/11/13)
Cross-Referenced in Primary Document:MPD583
Page 1 of 2
FORM FRM5121/1.1
Effective: 21/01/15
Therapeutic Apheresis Services
Request for Therapeutic Apheresis
Does the patient have any signification medical illness which would affect apheresis (significant
cardiovascular, clotting or allergies)?
Please provide relevant blood test / laboratory results
Medication:
Vascular Access
Are peripheral veins adequate for apheresis? Yes
No
Is an apheresis central line already in place? Yes
No
Will an apheresis central line be inserted? Yes
No
(If yes, please advise date of insertion)
Detail of member of staff completing this form
Name:
Grade:
Date:
Signature:
Phone Number
Email address:
(*To ensure confidentiality please ensure an nhs.net email address is provided)
For Use by NHS Blood and Transplant
Has the referral been accepted?
Yes
No
Comments:
(Template Version 01/11/13)
Cross-Referenced in Primary Document:MPD583
Page 2 of 2